Mobile Dog Training Problem Behavior Form
PART 1: Full Name
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First Name
Last Name
Phone Number
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-
Area Code
Phone Number
Do you receive texts to this number?
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Yes
No
E-mail
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What is the best way to contact you?
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Phone call
Email
Text
Physical Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
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Do you have more than one dog that needs training?
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Yes
No
Maybe?
PART 2: Your Dog's Information
If you have more than one dog who needs help, fill this part out for the main issue dog.
Dog's Name
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Breed or mix
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Dog's age:
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Dog's sex:
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Male
Female
Is your dog spayed or neutered?
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Yes
No
Soon
What age was your dog spayed or neutered?
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Type 'intact' if your dog hasn't been fixed
Dog's weight
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Coat color:
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Where did you get your dog? Please include NAME of rescue, shelter or breeder if applicable.
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Why did you obtain this dog? (Companionship, watchdog, sport competition, playmate for current dog, etc)
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How long have you had your dog?
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If you got your dog as a puppy, how old was s/he when you brought him/her home?
Is your dog crate trained?
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Yes, loves the crate
Attempted crate training
No longer uses crate
No, prefer to not use a crate
Would like to crate train, not sure how to get started
No, my dog hates a crate
Is your dog social with unfamiliar people?
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Seems to love just about everyone
Good with unfamiliar women
Good with unfamiliar men
Good with unfamiliar children
Selective
Tolerant (okay in their presence but doesn't like to be pet by strangers
Scared, avoids strangers
Aggressive (barks, growls, lunges, etc)
Is your dog social with unfamiliar dogs?
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Seems to love just about every dog
Good with big dogs
Good with small dogs
Good when off-leash only
Selective
Tolerant (okay in their presence, just doesn't want to be sniffed)
Not sure
Has your dog ever bitten a person (not including play mouthing/biting)?
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No
Not to my knowledge
I'm not sure if it was play or aggressive
My dog has growled but never bitten
Yes, but it left no mark
Yes, the bite bruised the skin
Yes, the bite left a shallow puncture
Yes, the bite left a deep puncture
Yes, the bite tore the skin
Yes, the bite left multiple punctures
Yes, my dog has bitten multiple times
If yes, who did your dog bite? (Relation to you and age if a child):
If yes, describe the injuries:
If yes, where on the person's body was the bite/s inflicted? (Ex: hand, face, thigh):
If yes, explain what was happening when the bite/s occurred:
What changes have you made to prevent the unwanted behavior/s?
Would you be willing to use a muzzle if necessary?
Yes, but my dog has never worn one
Yes, my dog already wears one & is okay with it
Yes, my dog wears one but hates it
No, I am not willing to use a muzzle
Does your dog receive daily walks/physical exercise?
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What equipment do you use to walk your dog?
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Regular, buckle collar
Martingale/Limited slip collar
Choke chain
Prong/pinch collar
No-pull or regular harness
Head harness (Halti, Gentle Leader, etc)
Other
Do you walk your dog on a Flexi or retractable leash?
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Yes
Sometimes
No
Has your dog ever worn an electronic/shock collar?
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No
Not to my knowledge
Yes, for training with me
Yes, for training with a trainer
Vibration only
Invisible/Underground fence only
Other
List any medications (including preventatives) your dog is currently on:
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If your dog has medical issues, please explain:
Does your dog have food allergies?
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What brand/s of dog food do you feed your dog?
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Feeding schedule?
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Free fed (food always available)
Schedule (eats everything)
Schedule (grazes)
Food drive
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High
Medium
Low
Depends
Not sure
No interest when food or treats are offered
Toy drive (retrieving, playing tug with people)
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High
Medium
Low
Depends
Not sure
No interest in toys
PART 3: Additional Dog's Information
Provide info for the second dog ONLY if this dog's behavior also needs to be addressed
Dog's Name
Breed or mix
Dog's Age
Dog's Sex
Male
Female
Is your dog spayed or neutered?
Yes
No
Soon
Dog's weight
Coat color:
Where did you get your dog? (ex: Rescue, breeder, friend, etc.)
Why did you obtain this dog? (Companionship, watchdog, sport competition, playmate for current dog, etc)
How long have you had your dog?
If you got your dog as a puppy, how old was s/he when you brought him/her home?
Is your dog crate trained?
Yes, loves the crate
Attempted crate training
No longer uses crate
No, prefer to not use a crate
Would like to crate train, not sure how to get started
No, my dog hates a crate
Is your dog social with unfamiliar people?
Seems to love just about everyone
Good with unfamiliar women
Good with unfamiliar men
Good with unfamiliar children
Selective
Tolerant (okay in their presence but doesn't like to be pet by strangers
Scared, avoids strangers
Aggressive (barks, growls, lunges, etc)
Has your dog ever bitten a person (not including play mouthing/biting)?
No
Not to my knowledge
I'm not sure if it was play or aggressive
My dog has growled but never bitten
Yes, but it left no mark
Yes, the bite bruised the skin
Yes, the bite left a shallow puncture
Yes, the bite left a deep puncture
Yes, the bite tore the skin
Yes, the bite left multiple punctures
Yes, my dog has bitten multiple times
If yes, describe the injuries inflicted:
If your dog bit a person, where on the person's body was the bite/s inflicted? (Ex: hand, face, thigh):
Explain the circumstances (what was happening that led up to the bite/s)?
Is your dog social with unfamiliar dogs?
Seems to love just about every dog
Good with big dogs
Good with small dogs
Good when off-leash only
Selective
Tolerant (okay in their presence, just doesn't want to be sniffed)
Not sure
Has your dog ever bitten another dog? (not including play biting/mouthing)
No
Not to my knowledge
I'm not sure if it was play or aggression
My dog has growled but never bitten
Yes, but it left no mark
Yes, the bite bruised the skin
Yes, the bite left a shallow puncture
Yes, the bite left a deep puncture
Yes, the bite tore the skin
Yes, the bite left multiple punctures wounds
Yes, my dog has bitten multiple times
Does your dog receive daily walks?
What equipment do you use to walk your dog?
Regular, buckle collar
Martingale/Limited slip collar
Choke chain
Prong/pinch collar
Harness (regular or no-pull)
Head harness (Halti, Gentle Leader, etc)
Other
Do you walk your dog on a Flexi or retractable leash?
Yes
Sometimes
No
Has your dog ever worn an electronic/shock collar?
No
Yes, for training with me
Yes, for training with a trainer
Vibration only
Invisible/Underground fence only
I'm not sure
Other
List any medications your dog is currently on:
If your dog has medical issues, please explain:
Does your dog have food allergies?
What brand/s of dog food do you feed your dog?
Feeding schedule?
Free fed (food always available)
Schedule (eats everything)
Schedule (grazes)
How many times a day is your dog fed?
Food drive
High
Medium
Low
Depends
Not sure
No interest when food or treats are offered
Toy drive (retrieving, playing tug with people)
High
Medium
Low
Depends
Not sure
No interest in toys
Additional Information
Veterinarian (Vet's name & clinic name):
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Date (approximate is okay) of last vet visit & reason:
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Has your dog had any training?
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Yes, group puppy class
Yes, group class adult
Yes, private lessons
Yes, sent to board & train
Informal training at home
Nope, but ready to learn
Currently in group class
Who was the trainer?
Check the issues you would like to discuss with trainer:
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Submissive/excitement urination
Pulling on leash
Demands attention
Stealing food
Resource guarding (food, toys, people, space) with dogs
Resource guarding (food, toys, people, space) with people
Runs away (won't come when called)
Aggressive behavior with people
Aggressive behavior with dogs
Separation anxiety
Anxious behavior
Fearful behavior
Excessive barking
Excessive energy
Behavior with guests
Jumping on people
destructive behaviors
House training
Barks on leash at other dogs
Barks on leash at people
Barks on leash at moving objects (cars, skateboards, etc)
Digs in yard
Mouthing
Obsessive compulsive behaviors (ie: spinning, light/shadow chasing)
Other
Please list the top 3 behaviors you would like to change (BE SPECIFIC):
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How long have you been dealing with the issue/s?
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How do you reinforce desirable behaviors?
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Praise
Food rewards
Toy rewards
Life rewards (walks, sniffing, playtime)
How do you address undesirable behaviors? (jumping, barking, etc)
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Interrupt
Redirect
Verbal reprimand (scold, say "no")
Correction with training collar
Physical reprimand
Other
Have there been any major changes recently? (move, pet or person passed away, diet change, etc)
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Please list any other pets in the home (name, breed, age):
Name/s of other adult people who live in the home:
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Age/s of children who live in the home or who visit often:
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How many hours a day does your dog spend alone?
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My dog is never alone
1-3 hours at a time
4-6 hours at a time
7-9 hours at a time
10-12 hours or more
Is your dog allowed on furniture?
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Couches
Human Beds
Only by invitation
Only on certain furniture
No
No, but my dog does anyway
Yes, my dog is allowed on all furniture
Where does your dog stay at night?
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Free range (inside)
Limited access in house
On human's bed, mostly
On dog bed, mostly
Crate
Outside
Where does your dog stay during the day?
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Free range (inside)
Limited access in house
Tethered to me (to assist in house training)
Outside
My dog goes to work with me
Other
Where does your dog stay when home alone?
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Free range (inside)
Limited access in home
Crate
Outside
My dog is never home alone
Does your dog go to dog daycare or playcare?
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Yes, regularly
Occasionally
No
How do you exercise your dog? Check all that apply
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Runs and/or walks around yard
Plays with other dog/s in the home
Walks
Jogging, running on leash
Swims regularly
Fetch, frisbee, etc
My dog doesn't get enough or any exercise
When guests enter my home, my dog:
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Walks up to greet guests
Ignores guests
Jumps
Barks a few times
Barks but settles after a minute or so
Barks non-stop
Whines
Wriggles
Hides
Pees involuntarily
Charges at guests
Growls
Threatens to bite
Has bitten
Dog's behavior changes depending on the person
is in a crate
is behind a gate
is in another room
is outside
I'm not sure, we haven't had or don't have many guests
Is there anything else you would like us to know?
I am interested in:
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One-Time Behavior Problem Consult $200
Comprehensive Behavior Program $450 (4 visits)
I understand the Problem Behavior fee is required to book (payable via Venmo, Cash App, or Zelle):
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I agree
What days/time frames would be best for you to schedule a consult?
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